Need Help

Must have been in an intimate-partner abusive relationship within the past six (6) months at the time of application and have ended that relationship.

Must be AT LEAST 21 years old.

Must have safe and stable housing.

Must have access to reliable transportation.

Must have access to safe, reliable, and appropriate childcare.

Must be committed to working with a case manager to set goals that will lead to financial independence.

Must be willing to work on identifying and establishing healthy relationship patterns through participation in support groups, individual therapy, and life skills classes.

Must be able to follow the program-participant schedule of Monday through Friday, 9:30am-2:00pm.

Must be committed to participating in community internships and working with an employment mentor/coach to increase employability and establish a healthy work ethic.

If a history of substance abuse, must be sober and in recovery for at least six (6) months prior to applying to the program, and actively involved in a substance abuse treatment program, or working a relapse prevention plan.

Name *

First

Last

Age *

DOB *

Address *

Street address, City, State, ZIP

Phone number *

Other names used

Email

Have you been convicted of a crime (other than traffic violations)? *

Yes

No

If yes, please state offense and date of conviction (a criminal record will not necessarily be cause for disqualification):

Doctor's name *

Where do you go for medical care? *

Medical card/insurance *

Emergency contact information: *

Preferred hospital in case of emergency: *

List any health conditions and/or physical limitations:

List all current medications and/or medication allergies:

Have you been diagnosed with a mental illness? *

Yes

No

If yes, list all current mental health diagnoses and when you were diagnosed:

Do you participate in mental health services? *

Yes

No

If yes, what service are you currently receiving (i.e.: therapy, medication management, psychosocial group)?

If receiving therapy and/or medication management, who do you see and when was your last appointment?

Are you still with your abuser? *

Yes

No

If no, how long ago did the relationship end?

What is your relationship to your abuser? *

Please check the option that best describes your current living situation: *

Shelter (DV or Homeless)

With family/friends

I have my own house/apartment

Transitional Housing Program (Step Stone or other)

Other

How do you get to where you need to go? (Check best option) *

Have my own vehicle

Public transit (bus)

Family/friends

Cab/taxi

Other

Do you have your high school diploma or GED? *

Yes

No

If yes, what school/program did you attend and what year did you graduate or earn your GED?

If you don't have your high school diploma, how many credits have you earned so far?

Have you taken the GED pretest?

If yes, what were your scores?

If you have earned credits OR have taken the pretest, can you provide verification? *

Yes

No

N/A

If you are currently working on your high school diploma or GED, can you provide verification? *

Yes

No

N/A

If you are not currently attending a college/university, technical college, or enrolled in a certficate-completion program, are you able to qualify for finanical aid (grants, scholarships, loans, work study)? *

Yes

No

Unknown

If no, why?

If you are not currently attending a college/university, technical college, or enrolled in a certificate-completion program, do you owe the school money BEFORE you are able to enroll again? *

Yes

No

N/A

List your last three (3) employers, starting with the most recent: *

Include: name of business; job title or duties; dates of employment; why you left; if you are eligible for rehire

I certify that my answers to the preceding questions are true and complete and that I have not knowingly withheld any information which might, if disclosed, affect my application unfavorably. I understand that any misrepresentation or omission of facts on this application may be cause for rejection of this application, or dismissal after employment. All offers of admittance into the program are conditional until verification of references. *